Nokea
The nurse is caring for a client with a history of a mastectomy who is receiving radiation therapy. The nurse should teach the client to:
- A. Apply lotion to the radiated area
- B. Expose the area to air daily
- C. Avoid sun exposure to the area
- D. Use a heating pad on the area
Correct Answer: C
Rationale: Avoiding sun exposure to the radiated area prevents further skin damage and irritation. Lotion, air exposure, and heating pads can worsen skin integrity.
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A client is medically cleared for ECT and is tentatively scheduled for six treatments over a 2-week period. Her husband asks, 'Isn't that a lot?' The nurse's best response is:
- A. Yes, that does seem like a lot.'
- B. You'll have to talk to the doctor about that. The physician knows what's best for the client.'
- C. Six to 10 treatments are common. Are you concerned about permanent effects?'
- D. Don't worry. Some clients have lots more than that.'
Correct Answer: C
Rationale: The most common range for affective disorders is 6-10 treatments. This response confirms and reinforces the physician's plan for treatment. It also opens communication with the husband to identify underlying fears and knowledge deficits.
The nurse is caring for a client with a history of a spinal cord injury who is experiencing autonomic dysreflexia. The nurse should:
- A. Place the client in a prone position
- B. Administer a vasodilator
- C. Insert a Foley catheter immediately
- D. Elevate the head of the bed
Correct Answer: C
Rationale: Autonomic dysreflexia is often triggered by bladder distension. Inserting a Foley catheter relieves the trigger. Vasodilators and positioning are secondary, and prone position is unsafe.
The physician has ordered intravenous fluid with potassium for a client admitted with gastroenteritis and dehydration. Before adding potassium to the intravenous fluid, the nurse should:
- A. Assess the urinary output.
- B. Obtain arterial blood gases.
- C. Perform a dextrostick.
- D. Obtain a stool culture.
Correct Answer: A
Rationale: Potassium supplementation requires adequate renal function to prevent hyperkalemia. Assessing urinary output ensures the kidneys are functioning before adding potassium.
The client is diagnosed with a pneumothorax. Which finding is most expected on auscultation?
- A. Bilateral crackles
- B. Diminished breath sounds on the affected side
- C. Wheezing throughout lung fields
- D. Rhonchi in the lower lobes
Correct Answer: B
Rationale: A pneumothorax causes collapsed lung tissue, resulting in diminished or absent breath sounds on the affected side. Crackles, wheezing, and rhonchi are not typical.
A postoperative TURP client is ordered continuous bladder irrigations. Later in the evening on the first postoperative day, he complains of increasing suprapubic pain. When assessing the client, the nurse notes diminished flow of bloody urine and several large blood clots in the drainage tubing. Which one of the following should be the initial nursing intervention?
- A. Call the physician about the problem
- B. Irrigate the Foley catheter
- C. Change the Foley catheter
- D. Administer a prescribed narcotic analgesic
Correct Answer: B
Rationale: The physician should be notified as problems arise, but in this case, the nurse can attempt to irrigate the Foley catheter first and call the physician if irrigation is unsuccessful. Notifying the physician of problems is a subsequent nursing intervention. This answer is correct. Assessing catheter patency and irrigating as prescribed are the initial priorities to maintain continuous bladder irrigation. Manual irrigation will dislodge blood clots that have blocked the catheter and prevent problems of bladder distention, pain, and possibly fresh bleeding. The Foley catheter would not be changed as an initial nursing intervention, but irrigation of the catheter should be done as ordered to dislodge clots that interfere with patency. Even though the client complains of increasing suprapubic pain, administration of a prescribed narcotic analgesic is not the initial priority. The effect of the medication may mask the symptoms of a distended bladder and lead to more serious complications.